An LPN improperly certified 64 MDS assessments as the RN MDS Coordinator over two separate employment periods, affecting 40 residents. The Administrator discovered the issue while reviewing an MDS and, after auditing a large number of assessments, found that the LPN had participated in the MDS process for many residents and had signed as the RN MDS Coordinator on a subset of those assessments, despite qualified RN staff and the DON being available to certify them. The facility could not confirm the prior RN MDS Coordinator’s process for ensuring proper review and certification because that RN was no longer employed.
The facility failed to accurately complete MDS assessments for three residents. One resident with a history of stroke and other comorbidities had a documented fall during a transfer attempt, but the subsequent MDS indicated no falls since the prior assessment. Another resident with Alzheimer’s disease and other conditions had multiple documented falls, including one with a head injury and another with a skin tear, yet the quarterly MDS recorded no falls and omitted the major injury. A third resident with an indwelling Foley catheter and orders for daily catheter care and urine output monitoring was coded on the MDS as always incontinent of urine, even though nursing staff confirmed the resident was always continent due to the catheter.
The facility failed to accurately code MDS assessments for several residents receiving respiratory services. Three residents with chronic respiratory conditions and orders for AVAPS, a non-invasive ventilation mode aligned with BiPAP, were incorrectly coded on the MDS as receiving invasive mechanical ventilation, despite observations showing no invasive ventilator use and RAI guidance limiting that code to closed-system ventilation via endotracheal tube or tracheostomy. Another resident with a history of acute respiratory failure, COPD, and other comorbidities was documented in progress notes and by an LPN and the DON as receiving continuous oxygen via nasal cannula, yet had no physician order for oxygen, no care plan addressing oxygen therapy, and an MDS that indicated no oxygen use, contrary to facility policy requiring accurate, comprehensive resident assessments.
Surveyors found that MDS assessments were inaccurately coded for two residents. For one resident with dementia and mood and anxiety disorders, bed handrails ordered and used for mobility were coded on the MDS as a daily physical restraint, despite no restraint assessment or care plan documentation and observation showing the rails did not restrict movement. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, documentation showed the pneumococcal vaccine was offered and declined, but the MDS recorded that the resident was not up to date because the vaccine had not been offered. Facility nursing leadership and the MDS nurse confirmed both MDS assessments were coded inaccurately.
MDS assessments were inaccurately coded for multiple residents. Several residents with documented level II PASRR determinations for serious mental illness were marked “No” on the MDS question about state level II PASRR status, and another resident’s MDS incorrectly showed no scheduled pain meds despite active routine orders for oxycodone ER and Lyrica during the look-back period.
Inaccurate MDS coding of hearing status. A resident with multiple chronic conditions had MDS and hearing assessments that documented hearing as adequate and no hearing devices, despite audiology records showing bilateral hearing aids/amplifiers. Observation and staff interviews confirmed the resident needed assistance placing and managing the hearing aids, and staff verified the devices were not coded on the MDS.
Incorrect MDS Coding for Ventilator Therapy and Medications The facility failed to code several resident assessments accurately in the MDS. Multiple residents using AVAP/AVAPS therapy by facial mask were coded as receiving invasive mechanical ventilation, even though the RT, RTM, MDS nurse, and DON confirmed the devices were non-invasive and no resident had an ET tube or trach. Two additional residents were miscoded for medication items, with one receiving an anticoagulant and another receiving a diuretic despite the MDS showing otherwise.
A resident with severe cognitive impairment and multiple diagnoses was documented in medical and dental assessments as having natural teeth with missing teeth and no dentures, while staff interviews revealed the resident actually had partial dentures. This inconsistency between staff knowledge and assessment documentation resulted in a deficiency related to inaccurate resident assessments.
A resident with diabetes and anxiety was documented in MDS assessments as having no dental issues, but was observed to be without natural upper teeth and reported losing teeth since admission without being offered dental assistance. Interviews with the MDS RN, an LPN, and the DON confirmed the inaccuracy of the resident's dental status in the MDS.
A resident was admitted with complex medical conditions and hospital records indicating buttock wounds, but the facility's admission assessment did not document these wounds. The MDS nurse, relying solely on hospital documentation and without conducting a personal assessment, recorded pressure injuries that were not present according to the facility's clinical evaluation. The discrepancy between hospital and facility findings was not addressed before completing the MDS assessment.
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